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OFFICE OF THE TOWN CLERK • • F
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Town of Southold, � lj
Judith T. Terry, Town Clerk
Town Hall, 53095 Main Road
P. O. Box 1179
Southold, New, York 11971 �0r•••,
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Telephone 1 �t
(516) 765-1801
TOWN OF 'SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
•
OPERATION PERMIT
, SEPTIC TANK or CESSPOOL
Operation Permit No. 274 Residential X
Non-Residential
Fee $ 10.00
Septic Cesspool x
NAME OF OWNER: Sali Stern and Jacqueline Wolfson
OWNER MAILING ADDRESS: 509 Sterling Place
Greenport, New York 11944
OWNER PROPERTY ADDRESS: 509 Sterling Place
Greenport, New YOrk
OWNER TELEPHONE NUMBER: 516-477-1426
TAX MAP NO. : Section 34 Block 3 Lot25
CROSS STREET: Champlin Place
TYPE OF SYSTEM: Septic Tank New Existing
Cesspool X - New Existing • X
Residential X Non-Residential
DATE OF PREVIOUS PUMP-OUT: unknown
Judith T. Terry
Southold Town Clerk
DATE: April 13, 1987 - ;-
(TOWN SEAL)
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OFFICE OF THE TOWN CLERKF OM;
Town of Southold �'� C'� t, Application No.�74/
Judith T. Terry, Town Clerk � .�
Town Hall, 53095 Main Road
14 Residential
P. O. Box 1179 _ i ;' Non-Residential
Southold, New York 11971 O � �
Telephone Oj
(516) 765-1801
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL ,
Operation Permit No.
Fee $ /G• }
DATE
OWNER NAME:N(, (At,\W W 6WSoh/ S%1V,
OWNER MAILING ADDRESS: 5-0I q•kr\'+ Q c(,'ue,
(A./4 m i)v N 1,l c q if
OWNER PROPERTY ADDRESS: "Sek e.- - -
OWNER TELEPHONE NUMBER: 01- tLtr).40
TAX MAP NO. : Section Block Lot zq
CROSS STREET: Cln1 Q;
TYPE OF -SYSTEM: Septic Tank New Existing
Cesspool ✓ New Existing `✓'
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT:_- 1Lyc4u :4
LOCATION MAP: Must be attached hereto before permit may be issued.,
(Locate building and system; give north arrow and feet
of distance, approximately, to building and closest road.) _ - -
/ : ozw_ , I
Signature of Ap.., icant
RECEIVED BY:G t 1 do
Townerk's ffice
DATE: -
APR 1 3 1987
Town Clark Southold
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